Vulvar dermatoses: A cross-sectional study of etiology, dermoscopic findings, and impact on the quality of life

Abstract

Context:

Vulvar dermatoses include a broad spectrum of inflammatory, infectious, pigmentary, and vascular entities presenting a diagnostic challenge with a significant impact on quality of life (QoL). Dermatoscopy has now become an integral part of the dermatologist’s armamentarium. It serves as a useful noninvasive adjunct to clinical examination.

Aims:

The aim of the study is to study the clinical, demographic, and dermoscopic features of common vulvar dermatoses.

Materials and Methods:

A cross-sectional descriptive study was conducted in 100 patients attending the Dermatology, Venerology and Leprosy Out patient Department (DVL OP) with vulvar lesions. For the dermoscopic assessment Dermlite 4, USA dermoscope was used and the pictures were recorded on a smartphone. Vulvar disease QoL index is used to evaluate the QoL at the time of diagnosis.

Statistical Analysis Used:

SPSS software was used for the statistical analysis. P <0.05 was considered statistically significant.

Results:

A total of 100 females were diagnosed with vulvar dermatoses with age ranging from 5 years to 70 years. Majority of the females belonged to the age group of 31–40 years with a mean age of 36.9 years. Among 100 patients, 76% (n = 76) were married. Infections (73%) constituted the most common etiology of vulvar dermatoses. Mild-to-moderate impairment is QoL.

Conclusions:

This study highlights the importance of enhancing awareness, promoting hygiene education, and incorporating dermoscopy in vulvar dermatology to optimize patient outcomes. We reiterate the impact of vulvar dermatoses on the QoL of the patients.

Introduction

The vulvar region is a complex mucocutaneous area which is seen at the conjecture of urinary, vaginal, and anal apertures, which makes it susceptible to various infectious and inflammatory conditions.[1] Vulvar dermatoses include a broad spectrum of inflammatory, infectious, pigmentary, and vascular entities with diagnostic challenges. Vulvar diseases may be specific to the vulva or may occur as part of a generalized disorder. Clinical features may be modified due to friction, moisture, and occlusion.[2] Accurate diagnosis is imperative to relieve the patients from the stigma and phobia associated with them and improve their quality of life (QoL).

Dermatoscopy has now become an integral part of the dermatologist’s armamentarium. It serves as a useful noninvasive adjunct to clinical examination. Dermatoscope provides a magnification of ×10 and employs a glass plate. Both contact and noncontact methods can be used, and a cross-polarized filter helps better visualize the deeper structures. Due to concerns of contamination and spread of infection, dermatoscopy has not been widely studied for genital mucosal dermatoses. Although biopsy is required for a definitive diagnosis, dermatoscopy is useful to identify atypical and suspicious lesions.[3,4]

Aim and objectives

The aim of the study is to study the clinical, demographic, and dermoscopic features of common vulvar dermatoses.

The objectives of this study are to correlate the clinical diagnosis and dermoscopic features and assess the impact of various etiologies on the QoL using the vulvar QoL index (VQLI).

Materials and Methods

This is a cross-sectional, descriptive study conducted on 100 patients attending the DVL OP during the period of 6 months with vulvar lesions. The study was carried out after taking approval from the institute’s ethical committee. The study was carried out after taking approval from the institute’s ethical committee.

Patients who were unwilling to give consent, had painful lesions, were pregnant, or were menstruating at the time of the study were excluded.

A thorough history, clinical examination, and dermoscopic assessment were carried out after obtaining written informed consent from the patients.

After cleaning the lesional site with 0.9% normal saline, dermoscopy was performed using DermLite 4, and the pictures were recorded on a smartphone. A disposable ice cap was used to prevent cross-contamination. The dermoscopic findings were analyzed for the following parameters: (1) background color, (2) scaling – color and distribution, (3) vasculature – morphology and distribution, (4) pigment network, (5) perifollicular findings – hyperpigmentation/depigmentation/plugging, and (6) Any other specific finding/pattern unique to the condition. All the dermoscopic findings were correlated clinically and documented.

Based on the etiology, the dermoscopic findings were described under the following categories – infections, inflammatory disorders, pigmentary, immunobullous, vascular, premalignant, and malignant conditions.

The VQLI is a validated 15-item questionnaire developed by Saunderson et al. in 2020 to assess the impact of vulvar diseases on a patient’s QoL. Each item is scored from 0 (not at all) to 3 (very much), giving a total score ranging from 0 to 45, with higher scores indicating greater impairment. The questionnaire evaluates seven domains: symptoms, daily activities, emotional well-being, sexual function, self-perception, treatment concerns, and future health worries. The total score is graded as follows: 0–5 indicates minimal impact, 6–15 indicates mild impact, 16–30 indicates moderate impact, and 31–45 indicates severe impact.[5]

IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, NY, USA) was used for the statistical analysis. P < 0.05 was considered statistically significant. Statistical significance was determined using the Chi-square tests for categorical variables and ANOVA for comparing means across groups. P < 0.05 was considered statistically significant.

Results

A total of 100 female patients with vulvar dermatoses were included in the study, with ages ranging from 18 to 70 years (mean age: 36.9 years). The majority (38%) belonged to the 31–40 years of age group, and 76% were married. Demographic parameters are summarized in Table 1.

Table 1.

Demographic parameters

Parameter	Distribution (%)
Age (years), mean	36.9
Age group (years) (most common)	31–40
Marital status
Married	76
Unmarried	24
Locality
Urban	72
Rural	28
Educational status
Primary	32
Secondary	54
Graduate	14

Pruritus (43%) was the most common presenting symptom [Graph 1]. Infections accounted for the majority of cases (73%), followed by inflammatory conditions (17%), pigmentary disorders (4%), vascular lesions (2%), immunobullous diseases (2%), and premalignant/malignant conditions (2%). Among infections, fungal etiologies, notably vulvovaginal candidiasis (VVC) and tinea cruris, were the most prevalent. Etiology of vulvar dermatoses and their respective mean VQLI score are given in Table 2.

Graph 1.

Common presenting symptoms

Table 2.

Etiology of vulvar dermatoses and their respective mean vulvar quality of life index score

Etiology	Number of patients	Mean VQLI
Infections
VVC	28	12.5
Tinea cruris	20	10.2
Herpes genitalis	6	19.4
Genital warts	10	15.2
Molluscum contagiosum	6	8.4
Folliculitis	3	7.2
Inflammatory conditions
LSEA	7	22.7
Psoriasis	4	19.2
Lichen planus	6	13.2
Pigmentary conditions
Vitiligo	4	17.4
Vascular conditions
Angiokeratoma of Fordyce	2	12
Immunobullous conditions
Hailey–Hailey disease	2	14
Malignant and premalignant conditions
Bowenoid papulosis	2	14

LSEA=Lichen sclerosus et atrophicus; VQLI=Vulvar quality of life index; VVC=Vulvovaginal candidiasis

The VQLI scores showed the highest mean impairment among patients with lichen sclerosus et atrophicus (LSEA) (22.7), followed by herpes genitalis (19.4), psoriasis (19.2), and vitiligo (17.4). Patients in the 20–40 years of age group reported the greatest QoL impairment, particularly in the sexual function domain. Age-wise distribution of the mean VQLI score is mentioned in Table 3.

Table 3.

Age-wise distribution of mean vulvar quality of life score

Age group	Mean VQLI
18–30	19.5
31–40	17.2
41–50	15.4
51–60	13.8
61–70	12.6

VQLI=Vulvar quality of life index

Statistical analysis revealed a significant association between background color and type of dermatosis (P < 0.01). Scaling patterns were significantly linked with fungal infections (P < 0.01). Vascular patterns were notably present in LSEA, psoriasis, and genital warts (P < 0.05). Pigment network differences were statistically significant in vitiligo and bowenoid papulosis (P < 0.01).

These findings emphasize the diagnostic value of dermoscopy in vulvar dermatoses and its correlation with clinical and QoL outcomes [Table 4].

Table 4.

Dermoscopic findings of common vulvar dermatoses

Dermatosis	Background color (%)	Scaling (%)	Vasculature (%)	Pigment network (%)	Perifollicular features (%)	Percentage of patients	P
Tinea cruris	Reddish-brown (70), grayish-black (60)	White perifollicular (60)	Red globules (65), black globules (80)	Absent	Black and red globules, perifollicular scales	20	Background color: P<0.01; scaling: P<0.01; vascular patterns: P<0.05
VVC	Whitish-pink (86)	Absent	None	Absent	Whitish amorphous masses (82), cottage cheese-like structures (57)	28	Background color: P<0.05; morphology: P<0.01
Genital warts	Pinkish-white	Absent	Red dots over projections (80)	Absent	Cauliflower-like lesions (100), finger-like projections (70), knob-like projections (30)	10	Vascular patterns: P<0.01; morphology: P<0.001
Molluscum contagiosum	Whitish-pink	Absent	Linear vessels at the edge (67)	Absent	Lobular amorphous structures (100)	6	Vascular patterns: P<0.05; morphology: P<0.01
Herpes genitalis	Erythematous	Absent	None	Patchy	Multiple yellowish-white vesicles on an erythematous background	6	Background color: P<0.05; Pigment network: P<0.01
Psoriasis	Dull red (50)	Absent	Uniformly distributed dotted vessels (75)	Absent	Dermoscopic Auspitz sign (100), dotted vessels	4	Vascular patterns: P<0.01; morphology: P<0.001
Lichen planus	Purple or gray–blue	Minimal or absent	None	Absent	Wickham striae (67), grey–blue globules and dots (83)	6	Morphology: P<0.01
LSEA	Whitish-pink (71), milky pink (100)	Absent	Red dots (57), purpuric red globules (71)	Absent	Structureless areas indicating sclerosis, red and purpuric globules	7	Background color: P<0.001; vascular patterns: P<0.05
Vitiligo	Glowing white (50)	Absent	Telangiectasia (50)	Absent	Koebnerization (50), absence of pigment network (100)	4	Pigment network: P<0.001; morphology: P<0.05
Angiokeratoma of Fordyce	Reddish-blue	Absent	None	Absent	Reddish-blue lacunae (100), whitish veil (100)	2	Morphology: P<0.001
Hailey–Hailey disease	Pinkish-white	Absent	None	Absent	Crumpled fabric appearance with pinkish-white areas separated by furrows	2	Morphology: P<0.01
Bowenoid papulosis	Pigmented papillomatous surface	Absent	Dotted vessels (100)	Brown–gray linear distribution (100)	Linear arrangement of brown-gray dots at periphery, papillomatous surface	2	Pigment network: P<0.01; morphology: P<0.01

LSEA=Lichen sclerosus et atrophicus; VVC=Vulvovaginal candidiasis

Discussion

Out of 100 patients of vulvar dermatoses, the majority belonged to the age group of 31–40 years with a mean age of 36.9 years, similar to the studies by Singh et al., Shaik et al., and Gokdemir et al.[6,7,8] This reflects the increased incidence of majority of vulvar dermatoses in peak reproductive age group women which will affect the sexual activity and QoL of the patients.

Infections followed by inflammatory conditions constituted the most common vulvar dermatoses in the present study in accordance with Pathak et al. and Shaik et al.[7,9] The most common infectious etiology in the present study was VVC, whereas Shaik et al. reported the tinea cruris as the most common etiology.[7] However, studies by Fischer reported dermatitis and lichen sclerosis to be the most common cause, followed by VVC and vulvodynia; Cheung et al. also similarly reported lichen sclerosis as the most common etiology of vulvar dermatoses in their study.[10,11]

Sullivan et al. and Gokdemir et al. reported an almost equal incidence of infectious and inflammatory etiology in their studies in contrast to the present study.[8,12]

This could be attributed to the lack of proper hygiene, absence of usage of barrier methods of contraception to prevent the transmission of sexually transmitted infection, improper shaving methods, frequent manipulation of lesions, improper hand hygiene, and wearing of tight clothing.

Among the inflammatory conditions (17%), LSEA (7%) had the highest incidence in concordance with the studies done by Pathak et al. and Sivayadevi and Anandan.[9,13] They reported the incidence of LSEA in 2.9% and 10% of the patients in their study, respectively. In our study, psoriasis constituted as etiology for only 4% of the cases in contrast to the study by Shinde et al., which reported psoriasis in 17% of patients.[14] Among the immunobullous disorders, Hailey–Hailey disease contributed for 2% of the cases in concordance with studies by Shaik et al. and Shinde et al.[7,14]

Vitiligo (4%) and angiokeratoma of Fordyce (2%) were the pigmentary and vascular lesions noted, respectively, in our study. However, according to a study done by Mannone et al., pigmented skin lesions of the vulva are present in 12%–19% of the women who have had gynecological examination.[15]

Mild-to-moderate grade of impairment in QoL due to various etiologies was found in the present study. A severe impact on QoL was found in the patients suffering from LSEA. Maximum impairment of QoL was found in the reproductive age group of 20–40 years, with the maximum scoring domain being sexual function.

There are limited studies on the impact of specific vulvar dermatoses on the QoL. Irene et al. reported that majority of VVC patients had a mild-to-moderate impairment of QoL, similar to the present study.[16] In a study by Wu M et al., 22% of LSEA patients had severe impairment on QoL. Another study reported an immense impact on QoL in patients of VVC, Vulvar Lichen Planus (VLP), and LSEA. They reported that patients of VVC had a severe impact on QoL in contrast to the present study.[17] This reiterates the importance of accurate diagnosis of vulvar dermatoses, and dermoscope helps in earlier diagnosis. VQLI score can also be utilized for the monitoring of treatment response. A clinically significant treatment response is defined as at least a 50% reduction in baseline VQLI score.[17]

A comparative analysis of clinical findings reported in literature is summarized in Table 5.

Table 5.

A comparative analysis of clinical findings

Parameter	Present study	Comparable studies	Remarks
Age group (years)	31–40 years most affected (mean: 36.9)	Singh et al., Shaik et al., Gokdemir et al.	Peak reproductive age group; may affect sexual and psychosocial health
Common symptom	Pruritus (43%)	Shaik et al., Harlow et al.	Pruritus significantly affects QoL
Most common etiology	Infections (73%) > inflammatory (17%)	Pathak et al., Shaik et al. infections Fischer et al. – lichen sclerosus	Etiology may vary by region and hygiene habits
Infectious cause	Fungal (especially, candidiasis) > viral (herpes)	Pathak – VVC, Shaik – tinea cruris	Tropical climate may explain higher fungal prevalence
Inflammatory dermatoses	Lichen sclerosus most common (7%)	Pathak et al., Sivayadevi et al.	Known for chronicity and significant QoL impact
QoL (VQLI)	LSEA had the highest mean score (22.7); sexual function most affected	Wijaya et al. – 22% severe Irene et al. – mild to moderate	VQLI is a helpful tool for measuring disease burden and treatment response

VQLI=Vulvar quality of life index; VVC=Vulvovaginal candidiasis; QoL=Quality of life; LSEA=Lichen sclerosus et atrophicus

Dermoscopic findings of each vulvar dermatoses in our study are as follows:

Tinea cruris

Tinea cruris typically presents with erythematous, pruritic, and annular lesions on the vulvar region. It may be accompanied by scaling and a well-defined border. Most common dermoscopic findings in tinea cruris were reddish-brown background (14/20), grayish-black background (12/20), white perifollicular scales (12/20), black globules (16/20), and red globules (13/20) [Figure 1]. Ankad et al. reported similar findings in the cases of tinea corporis.[18] Knöpfel et al. also describe the presence of perifollicular scales in fungal infections.[19]

Figure 1.

Reddish-brown background (blue arrow), white perifollicular scales (brown arrow), and red globule (red arrow)

Vulvovaginal candidiasis

Patients with VVC typically present with pruritus, vulvar erythema, and white discharge resembling cottage cheese.

Dermoscopic findings seen were whitish-pink structureless areas (24/28), whitish amorphous masses (23/28), and cottage cheese-like structures (16/28) [Figure 2]. The structureless areas and amorphous masses reflect the acute inflammatory reaction in candidiasis; Chatterjee and Neema describe cottage cheese-like scales as typical dermoscopic features of cutaneous candidiasis, consistent with the current study.[20] Lekkas et al. reported the presence of linear blood vessels in the center, which were not found in our cases.[21]

Figure 2.

Whitish-pink structureless areas (blue arrow), whitish amorphous masses (red arrow), and cottage cheese-like structures (yellow arrow)

Genital warts

Genital warts appear as cauliflower-like or finger-like projections, often painless but pruritic. They may occur on a red- or flesh-colored base. Dermoscopic findings seen in genital warts were cauliflower-like lesions (10/10), pinkish-white finger-like projections (7/10), knob-like projections (3/10), and red dots over projections (8/10) [Figure 3]. Sonthalia et al. reported similar dermoscopic features, such as finger-like projections and cauliflower-like surfaces in genital warts.[22] Dong et al. highlighted the presence of vascular patterns, such as red dots over projections, as a common finding in warts, matching the current study’s observations. However, the vascular patterns were less appreciated in our study due to higher Fitzpatrick skin types.[23]

Figure 3.

Cauliflower-like lesions (blue arrow) and pinkish-white finger-like projections (orange arrow)

Molluscum contagiosum

Molluscum contagiosum presents as umbilicated papules with a central dimple on a erythematous base, often seen in clusters.

Dermoscopic findings of molluscum contagiosum were whitish-pink lobular amorphous structures (3/3) and linear vessels at the edge of the lesion (2/3) [Figure 4]. Zaballos et al. describe molluscum contagiosum as showing polylobular and amorphous structures with characteristic vascular patterns, which align with the current study.[24] Morales et al. also reported linear vessels at the periphery as a frequent finding in molluscum contagiosum.[25]

Figure 4.

Whitish-pink lobular amorphous structures (blue arrow)

The distinct lobular appearance and peripheral vascular structures are critical for diagnosing molluscum and differentiating it from other papulonodular lesions like genital warts.

Herpes genitalis

Herpes genitalis is characterized by painful vesicles, often grouped on an erythematous base, progressing to ulcers and crusting. Dermoscopic features of herpes genitalis were multiple yellowish-white vesicles on an erythematous background with patchy pigment network. These findings were in accordance with Narkhede et al.[26] The presence of patchy pigment network helps in distinguishing the lesions of herpes genitals and pemphigus vulgaris.

Folliculitis

Dermoscopic features of folliculitis were erythematous follicular papules and pustules with red dots. Chatterjee and Neema reported folliculocentric lesion with pustule around hair follicle and surrounding red dots and clods consistent with the current study.[20] Martín et al. also reported similar findings, highlighting the inflammatory nature of the lesions.[27]

Psoriasis

Psoriasis presents with well-defined, scaly plaques, often erythematous, and located in flexural or genital areas. Dermoscopic features of psoriasis were uniformly distributed dotted vessels (3/4), dull red background (2/4), and dermoscopic Auspitz sign (4/4) [Figure 5]. Lekkas et al. describe dotted vessels and a dull red background as characteristic of psoriatic lesions, matching the current study. They also reported diffuse white scales and the Auspitz sign as typical findings in psoriasis on nongenital skin. However, scaling is less prominent in the vulvar area; hence, scaling was not seen in the present study.[21] Lacarrubba et al. reported homogeneously distributed, dilated, and dotted vessels on an erythematous background similar to the present study.[28]

Figure 5.

Dermoscopic Auspitz sign (blue arrow)

Lichen planus

Dermoscopic features of lichen planus were gray–blue globules and dots (4/4) and Wickham striae (4/4) [Figure 6]. Lacarrubba et al. highlight gray–blue globules and Wickham striae as classic dermoscopic features of lichen planus, consistent with the current findings.[28]

Figure 6.

Gray–blue globules (blue arrow) and dots and Wickham striae (yellow arrow)

Lichen sclerosus et atrophicus

LSEA presents as hypopigmented, atrophic plaques with skin thinning and erosions, primarily affecting the labia. Dermoscopic features of LSEA were whitish-pink background (5/7), milky pink structureless areas (7/7), red dots (4/7), and purpuric red globules (5/7) [Figure 7]. Lacarrubba et al. also reported whitish-pink areas suggestive of sclerosis.[28] Kamat and Vinay described red dots and purpuric globules as indicative of underlying vascular changes in LSEA.[3]

Figure 7.

Whitish-pink background (blue arrow), milky pink structureless areas (yellow arrow), red dots and purpuric red globules (brown arrow)

Vitiligo

Vitiligo presents as depigmented macules or patches; dermoscopic features of vitiligo were absent pigment network (2/2), glowing white areas (2/2), koebnerization (2/2), and telangiectasia (2/2) [Figure 8]. Similar findings were reported by Varma et al. in patients with genital vitiligo.[29] Perifollicular pigmentation was not prominent in the vulvar area in our study, unlike in extragenital areas.[29]

Figure 8.

Absent pigment network (blue arrow), glowing white areas (yellow arrow), and telangiectasia (brown arrow)

There can be overlap between vulvar LSEA and vulvar vitiligo which is referred as “vitiligoid” form of Lichen sclerosus (LS).[30] Hence, dermoscopic features aid in differentiating both the conditions.

Angiokeratoma of Fordyce

Dermoscopic features of angiokeratoma of Fordyce were reddish-blue lacunae (2/2) and whitish veil (2/2) [Figure 9]. Kamat and Vinay also described reddish-blue lacunae and a whitish veil as characteristic dermoscopic findings in angiokeratoma.[3] Jha et al. also report similar findings of whitish veil in their evaluation of angiokeratoma lesions.[31]

Figure 9.

Reddish-blue lacunae (blue arrow) and whitish veil (orange arrow)

Hailey–Hailey disease

Seen dermoscopically as pinkish-white areas separated by furrows, giving a crumpled fabric appearance [Figure 10] in accordance with the findings reported by Narkhede et al.[26] These features help differentiate it from other vesicular and erosive dermatoses.

Figure 10.

Pinkish-white areas (blue arrow) separated by furrows (yellow arrow), giving a crumpled fabric appearance

Bowenoid papulosis

Dermoscopy revealed a pigmented papillomatous surface, brown–gray dots arranged in a linear distribution at the periphery of the lesion, and widespread dotted vessels [Figure 11] in concordant with study by Dong et al.[23]

Figure 11.

Pigmented papillomatous surface (blue arrow), brown–gray dots arranged in a linear distribution at the periphery of the lesion (brown arrow)

Conclusions

This study highlights the importance of enhancing awareness, promoting hygiene education, and incorporating dermoscopy in vulvar dermatology to optimize patient outcomes. We reiterate the impact of vulvar dermatoses on the QoL of the patients. The study demonstrates distinct dermoscopic patterns in vulvar dermatoses, highlighting unique features in the vulvar region compared to other body areas. Conditions such as psoriasis and tinea cruris exhibit reduced scaling in the vulvar area, likely due to the thin, moist environment that differs from keratinized skin. Similarly, vascular patterns, such as red dots in genital warts and Wickham striae in lichen planus, are often subtler in the vulva, particularly in patients with darker skin, where pigmentation can obscure vascular structures. Vitiligo in the vulvar region lacks the perifollicular pigmentation typically seen elsewhere, likely due to fewer hair follicles, and LSEA tends to show more erosions due to friction and moisture. Importantly, dermoscopy also aids in identifying premalignant changes, as seen in bowenoid papulosis, where a linear arrangement of brown–gray dots provides a noninvasive diagnostic marker.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.